05 Apr GP at scale – we need to talk about sustainability

General practice needs to be in a good shape if it is to drive the upcoming transformation – coping with demand, recruiting strongly, soundly based and well placed to innovate. But how can all of this be achieved?

Few would disagree that general practice is under considerable pressure. Recruitment of GPs is very difficult, and workload pressures are rising. Reports of practice closures are commonplace.

Looking through the published STP plans, one gets the sense that the ‘T’ has been given more attention than the ‘S’. STP plans are, of course, the vehicles for implementing the new models of care described in the Five Year Forward View, and if general practice is to provide the basis of these then both elements are important

Can GP at scale be the answer?

One school of thought is that resource, not change, is needed to stabilise general practice before it is able to move forward. Others would argue that resource alone is not the solution, and that a new approach is essential. They would say that small scale, independent general practice is unable to deliver the level of service coordination and integration that is needed if it is to become the foundation of a wider provider of non-hospital services.

Large scale general practice has been developing over recent years, with federations the predominant model. Most were initiated by CCGs that encouraged their development and provided resource to support them. Some have led to stronger structures such as super partnerships or limited companies which bind partners more tightly together.

The aims have fallen into three broad categories:

To generate benefits of scale for practices, by enabling the sharing of support functions and overheads

To bring practices together to deliver specific services, often through enhanced service frameworks or similar

To facilitate planning of, and involvement in, the new models of care (Multispecialty Community Providers or Accountable Care Organisations)

Can a one off influx of cash help?

It appears that most large scale groups are funded via non-recurrent, external sources, including local commissioners and national schemes such as Challenge Fund or Vanguard. What will happen when these funds have been spent?

If this is true, then sustainability in general practice has two distinct, but related, aspects to it. The first is that general practice as it is currently configured is struggling because of insufficient resource, the second is that the new models of provision are reliant on external, one off funding sources and therefore not independently sustainable.

This is a critical question, particularly if large scale groupings are seen as the solution to a sustainable general practice sector in the coming years.

Last year Rebecca Rosen of the Nuffield Trust reported that three-quarters of practices were working collaboratively in large scale organisations, and noted that ‘larger scale can help to improve sustainability…through operational efficiency and standardised processes, maximising income, enhancing the workforce and deploying technology’. However she also noted that the ‘resources needed to develop and maintain the organisation and introduce these approaches are significant’

External resource is important, to help establish a new organisation and provide initial ‘pump priming’. After that, the provider must be sustainable within the funding envelope available to general practice. If it is not, then we can expect to see large numbers of large scale general practice providers to close in the coming period, as the initial funding runs out.

What’s next?

Time will tell. If GPs are to ‘self fund’ large scale providers, as they must if they wish to retain control, then they will need to see clear evidence of benefit, whether this is financial pay back or alternatives such as improved recruitment, support for quality improvement or greater system influence.

More work is needed, and it is needed soon. Are GPs themselves willing to fund their new groups via subscriptions or profit sharing, or will they look for funding through the new models of care and the new contract? It may be possible to sustain core general practice through development of an MCP or similar, bringing in additional funding for the wider service offering involved, but I am not aware this has yet been clearly demonstrated.

These are questions that urgently need addressing. Do readers have any thoughts or experiences to share?

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